Provider Demographics
NPI:1518727387
Name:STEVEN PERETIATKO MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:STEVEN PERETIATKO MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERETIATKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-236-0461
Mailing Address - Street 1:PO BOX 872
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91376-0872
Mailing Address - Country:US
Mailing Address - Phone:818-518-7226
Mailing Address - Fax:818-671-2225
Practice Address - Street 1:1303 MABLE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1119
Practice Address - Country:US
Practice Address - Phone:209-857-3400
Practice Address - Fax:818-671-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-20
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA190660OtherMEDICAL LICENSE